Commission Chairman, David Anderson, Proposes Mental Health Trust Fund

November 30, 1999

It is a great privilege to be here today, to convene the Commission’s last meeting of the year. As we approach the new year – and, indeed, the beginning not only of a new century, but of the next millennium – it is appropriate to consider the progress that has been made in the last two years.

We have witnessed an increase in funding to make new atypical antipsychotic medications available virtually to all who need them. And money has been made available to significantly reduce the waiting list for individuals with mental retardation who are in need of services. We have seen the census in our state psychiatric hospitals substantially reduced, the network of community services increased, and new innovative approaches to care delivery – like PACT teams – proliferate throughout the Commonwealth.

These reforms, to mention just a few, are the result of the hard work not only of this Commission and the Department of Mental Health, Mental Retardation, and Substance Abuse Services, but of the Governor, the General Assembly, patient advocates and family members, and professionals throughout the Commonwealth. By coming together, we have been able to accomplish much. In a holiday season of joy and good cheer, certainly there is much to be cheerful about for those who care about individuals with mental illness and mental retardation, and those in the grips of addiction and substance abuse.

It is with some trepidation, then, that I must sound a dissonant note. There is no unwritten law of progress that says that things can never regress to the way they were. While Governor Gilmore and many members of the incoming General Assembly may have a strong commitment to our cause – and they most certainly do – they will not always be where they are today. While we have done much to improve our system of delivering services to those who need them, we have as yet failed to adequately address the that part of our system most in need of change: our state psychiatric hospitals.

Virginia is home to the oldest psychiatric hospital in North America: Eastern State Hospital. Established in 1773, at the time it was a monument to the best impulses of the American Enlightenment and to the best that is within us as Virginians. Like those of us who sit on this Commission, the founders of Eastern State sought to combine the best available scientific and technological advances with a practical compassion that would improve the quality of life for those with serious mental illness.

Today, Eastern State Hospital can boast some of the most talented and dedicated staff of any psychiatric hospital in the country. I have the highest regard for these men and women who have dedicated their lives to the treatment of those with serious mental illness. It is a sad fact, however, that their efforts are hobbled by the very institutional structure within which they serve. Eastern State is and remains a 19^th Century institution struggling to practice 21^st Century psychiatry and medicine.

Surely, this must be a source of unceasing frustration for progressive and innovative staff to serve in a context and setting that inherently works to defeat their efforts. There must be many days when they feel like Sisyphus, that ancient Greek of mythology who was condemned for eternity to roll a boulder up the mountain only to watch it roll back down over and over again.

Worse still, the hospital as presently configured represents a misallocation of tens of millions – perhaps hundreds of millions – of dollars that are being inefficiently used or not used at all on behalf of patients.

As frustrating as that may be for staff, how devastating for the patients and their families. It is they, after all, who feel the full effect of that downward slide.

For those who do not know, or have forgotten, how deep and dark that valley of stone truly can be, I would call to your attention the results of the U.S. Justice Department investigation.

In a 1994 letter to Governor Allen, the Justice Department found that patient diagnoses were made with "little consideration … given to patient symptoms, history, or cognitive assessments." Many patients received "inconsistent, unreconciled, diagnoses" and many diagnoses were "erratic, inconsistent, or inaccurate." As a result of improper diagnoses and "the absence of interdisciplinary team involvement … treatment plans for patients … fail[ed] to meet their needs."

Further, the Justice Department found that there was inadequate staffing in the hospital which led to patients being subjected to unsafe conditions and not receiving adequate medical care. Additionally, patients were subjected to the unreasonable use of physical restraint.

Drug treatments at Eastern State were improperly used and improperly monitored. Drugs were administered where "there was no professionally acceptable justification for their use" and it was "common practice … to simply add drugs when the patient fails to respond to the current drug therapy."

The Justice Department also found that the level of general medical care was inadequate. "The failure to intervene in a timely manner ranges from such things as the failure to follow-up abnormal lab reports, adjust medications for the patients at risk of suicide, perform lab tests when ordered, or act when patients exhibit severe weight loss, to situations where patients are not transferred to general hospital facilities when necessary."

Perhaps most the most disturbing thing about the Justice Department’s letter is how it returns again and again to the inappropriate treatment of Eastern State’s elderly population.

The DOJ found that assessment of elderly patients routinely ignored examining the possibility of their suffering from calcium deficiencies – even though such deficiencies can lead to psychological symptoms. Similarly, "dementia work-ups are often incomplete due to the absence of neuroimaging studies which can reveal evidence of a tumor, hematoma, or a stroke." The Department found that physicians did not consistently participate in evaluations of elderly patients with histories of a fall and that often such patients were confined to "gerichairs" without a physician’s evaluation or assessment. Finally, the Department found that geriatric patients were often put on drug treatments without proper monitoring for increased dizziness or lowered blood pressure.

I believe that the problems that besieged Eastern State stem from the fact that it was an antiquated system for delivering mental health care services. I believe that, despite the heroic efforts of the staff, it remains one today.

I am not suggesting that no improvement has occurred at Eastern State Hospital since 1994. There has been very significant improvement. Indeed, to date, Eastern State has met its burden under CRIPA; it meets the minimum requirements of the due process clause of the United States Constitution. Yet, let us recall that the Constitution is not a code of professional conduct – far less a code of best practices for mental health professionals. It is, simply, a restraint upon government. The due process clause sets a minimum standard – a floor – below which government may not fall without seriously mistreating its own citizens. In reaching that standard we merit no badge of honor; rather, we have begun to erase a stain on our honor.

However, problems persist at Eastern State. Thus, in the spring of 1998 – four years after the initial DOJ investigation -- Dr. Jeffrey Geller would report treatment planning proceeds illogically; that rather than determining what a patient needs, the hospital first "ascertains what it currently has available, then ascertains what the patient’s needs are but confined to the list of what is available, and then the patient is assigned accordingly." Dr. Geller observed that in certain programs there is a "disconnect between where patients are, where human service care workers are, and where registered nurses are" and that certain programs suffer from "major backsliding." Dr. Geller also found that the individual patient is "lost" in the hospital’s treatment planning process; that "preparing patients for community placements" simply "does not appear to be occurring; and that "there is too frequently a lack in the treatment team specifically addressing whether or not Eastern State Hospital continues to be an appropriate setting for a specific patient."

Reading the Geller reports on Eastern State, it is hard to escape the conclusion that, despite the best efforts of all involved, the institution is structurally deficient. It was and remains, at bottom, a 19^th Century institution trying to deliver 21^st Century health care.

If the progress we have made over the last two years is to endure, if we are to create a legacy for those most vulnerable among us who depend upon our mental health care delivery system, then we must begin to address the issue of restructuring and reforming our psychiatric hospitals. That is why, shortly after Governor Gilmore appointed me to serve as Chair of this Commission, I asked Commissioner Kellogg to develop a plan for restructuring Eastern State Hospital – a plan that would be submitted to the General Assembly in the form of legislation.

For far too long, the Commonwealth’s approach to Eastern State has been to preserve the status quo at all, and ever increasing, costs. Given the revolutions that are occurring in how patients can be treated, a blind resistance to change will only result in Eastern State becoming more antiquated with each passing day.

If we continue on the course we currently are on, we will spend millions upon millions of dollars in the struggle to provide merely adequate care at Eastern State. There is, of course, no guarantee, no matter how much we spend, that we can preserve the status quo against the miraculous changes that are occurring in mental health care. Nor is it clear to the dispassionate observer why we should do so.

That is why I made very clear to Commissioner Kellogg that all our planning must proceed in a different way.

First, we must ascertain what is best for the patients of Eastern State, then we must develop a delivery system which provides the best care to the most people in the most efficient way. Clearly, that is not happening today. The plan which Commissioner Kellogg will present promises to provide the best treatment for the patients – creating an infrastructure of community-based facilities and services for appropriate individuals with mental illness and partnering with private care givers for those who need long-term care. Importantly, the plan would keep Eastern State patients within the Greater Williamsburg – Hampton Roads area.

Second, we have seen in the past honest efforts at reform defeated by the politics of suspicion, division, and fear. We must not let that happen again. The restructuring and reform that needs to occur at Eastern State cannot happen by the actions of this Commission alone. Nor can it occur through actions of the Governor and the General Assembly in isolation. There must be full consultation and coordination with all stakeholders, including patients, patient advocates, patients’ families, local government, Eastern State employees and the College of William and Mary.

Third, the plan must take into account the staff of Eastern State. They have served long and honorably. The staff must be brought to the table as we plan the future of this institution – those who have served so long cannot be left behind. We must take the future of staff members into consideration as well.

Finally, the plan must maximize resources currently within the system that are not being used or being sorely underutilized. Eastern State Hospital occupies 550 acres of land nestled between Colonial Williamsburg and the College of William and Mary. The plan we have developed would call for parcels of this property to be sold for development and the proceeds to be placed in an independent trust fund to be used to improve our mental health, mental retardation and substance abuse services delivery system. First call on these funds, of course, would go towards the benefit of the current patients at Eastern State. Excess funds would go for uses throughout the system. The fund would have an independent board appointed by the Governor, the Speaker of the House, and the Senate Committee on Privileges and Elections. This fund could provide a very substantial legacy for the future.

I am very proud of the work of Commissioner Kellogg and his colleagues in developing this plan. I believe that it points the way out of the wilderness. And I am deeply gratified by the support of John Favret, the Director of Eastern State Hospital.

Following the presentations by Commissioner Kellogg and Dr. Geller, I will have a motion to put before the Commission. I hope you will approve it. I am not unmindful how difficult this effort at reform will be. Some will seek to exploit our fears, rather than to enliven our hopes. Some will seek to sow division, rather than reach out to build consensus. Some will cling blindly to the status quo and call our efforts misguided – or perhaps even worse.

Let us not be governed by our fears. Instead, let us be inspired by our vision. As those we seek to help lack a voice and lack power, let us be filled with boldness and determination.

Let me emphasize that what we are seeking here today is a beginning, not an end. We seek a process that is as inclusive as possible. A process that will result in a permanent legacy we can all be proud of. One thing we know, as more people come to the table and share their talents, their insights, and their concerns – our plan will change as well. It will become better and better because it will incorporate the strength that is in each of us.

We stand at a crossroads. The time for meaningful reform is now. If that reform is to occur, then it is we here today who must make a beginning. I hope that each of you on this Commission and all of you in attendance here today will join me on that journey.